J Clin Neurol.  2015 Jul;11(3):275-278. 10.3988/jcn.2015.11.3.275.

Recurrent Cardioembolic Stroke Treated Successfully with Repeated Mechanical Thrombectomy within the Acute Index Stroke Period

• Lee Y
• Yi H
• Kim BM
• Kim DJ
• Kim SH
• Nam HS
• Heo JH
• Kim YD

• KMID: 1894568
• DOI: http://doi.org/10.3988/jcn.2015.11.3.275

Abstract

BACKGROUND
The safety of repeated mechanical thrombectomy within the acute stroke period has not yet been clearly demonstrated. We describe herein a patient who was successfully treated with repeated mechanical thrombectomy within the acute index stroke period.
CASE REPORT
A 50-year-old woman with atrial fibrillation presented with left-sided weakness caused by occlusion of the right middle cerebral artery (MCA). Emergent mechanical thrombectomy with the Solitaire device achieved complete recanalization. The left MCA occlusion redeveloped at 6 days after the first treatment, at which time her international normalized ratio (INR) was 2.3. Endovascular thrombectomy was reattempted rapidly and complete recanalization was achieved again. Her neurologic symptoms resolved after the thrombectomy.
CONCLUSIONS
This case demonstrates that repeated mechanical thrombectomy can be safely and successfully performed even in a patient with a high INR and a recurrent stroke during the acute period after the index stroke.

Keyword

stroke; atrial fibrillation; repeated thrombectomy

MeSH Terms

Atrial Fibrillation
Female
Humans
International Normalized Ratio
Middle Aged
Middle Cerebral Artery
Neurologic Manifestations
Stroke*
Thrombectomy*

Figure

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  Fig. 1 Digital subtraction angiography (DSA), brain MRI, and coronary computed tomography (CT) of the patient. A: Initial DSA showing thromboembolic occlusion of the right distal internal carotid artery (ICA). B: Mechanical thrombectomy with the Solitaire (ev3 Inc.) device against the right distal ICA and middle cerebral artery (MCA), which achieved complete recanalization. C: Diffusion-weighted MRI revealing an acute infarction in the right insula and basal ganglia. D: Coronary CT demonstrating a 22-mm-sized thrombus (white arrow) in the left atrial appendage. E: The patient suffered a second stroke 6 days after the index stroke; DSA revealing embolic occlusion of the left proximal MCA. F: The left MCA was successfully reopened after mechanical thrombectomy using the suction thrombectomy and Solitaire (ev3 Inc.) devices. G: Follow-up diffusion-weighted MRI revealing a slightly increased signal intensity in the left basal ganglia. H: Follow-up coronary CT after the second stroke confirming disappearance of the thrombus in the heart.

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  Fig. 2 Hematoxylin and eosin staining (original magnification ×40). (A) The extracted thrombus from the index stroke exhibited a large number of red blood cells (RBCs), whereas (D) the clot extracted from the second stroke appeared to have fewer RBCs and a larger amount of fibrin. However, antiglycophorin-A staining (original magnification ×40) revealed that the thrombus extracted following the first (B) and second (E) strokes were erythrocyte-rich thrombi. (C) Detail of panel A showing intact RBCs and granulocytes (white arrow). (F) Detail of panel D revealing degraded RBCs and granulocyte apoptosis (white arrowhead).

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